1. Ethics in occupational health: An African perspective
ARAOH / SASOM Congress
August 2014
Leslie London, UCT; Godfrey Tangwa, University of Yaounde , Reginald Matchaba-Hove, University of Botswana , Nhlanhla Mkhize, University of KwaZulu-Natal, Remi Nwabueze, University of Southampton, Aceme Nyika, Wits University, Peter Westerholm, Uppsala University
Supported by the Wellcome Trust

2. Ethics in Occupational Health
Growing international interest
Changing nature of work and globalisation
Reliance on Ethical Codes, especially in developing countries
ICOH initiated review of its Ethical Code in 2009 to … increase relevance to working populations from the most vulnerable settings across the globe

3. Africa Workgroup established 2010; ToR:
South Africa, Cameroon, Zimbabwe(Bots) Tanzania (SA), Nigeria (UK) ICOH brd memb (Swedish
Occupational Medicine, Bioethicist, Legal Psychology (indigenous knowledge), molecular biologist
Africa Workgroup established 2010; ToR:
Examine pertinence of bioethical values in African context; Conditions of particular relevance for African region with emphasis on the interaction of culture and values: recommendation for ICOH code
Iterative meetings, discussions

4. Outline Ethics versus law Globalisation and power
Vulnerability at the workplace
Consent
Stigma
No distinction between work and home
A framework for balancing individual autonomy and communal values – ubuntu and other African philosophical concepts

5. Ethical Codes vs. Regulation
Research Ethics ‘well-developed’ - ?OH practice
Legal backing: akrasia, self-interest, etc
Impunity when in the developing world: Trovan, Tenofovir trials
Few African countries have legal frameworks
Advantages of guidelines:
Law straightjackets options
Moral motivations preferable
Ethical guidelines portable across national boundaries unlike law

6. Globalisation Pervasive: no country untouched
Not simply passive process
Global competition  human resource practices must be competitive
Winners and losers
Surrender of state sovereignty
In Africa: SAP’s, FTZ’s
Globalisation of culture and norms:
How to ensure ICOH Code is able “to protect and promote workers’ health and wellbeing at work throughout their working lives …”

7. Vulnerability Power differences Safety as cost to production
Victimisation, distrust
Other dimensions of power: Gender discrimination; sexual harrassment
What makes vulnerability unique in Africa?
The extent and scale
Specific historical context
Weakened state capacity

9. Vulnerability: limiting capacity to act for H&S
Extensive migrancy
Harsh conditions in the extractive industries
Migrancy and human dignity
Repatriation of miners with TB, silicosis
‘White plague, black labour’… Not only SA – Ghana, Tanzania, et al

10. Vulnerability in African workplaces?
Displacement  refugees  marginal work
Informal sector
Poverty and contextual factors
Weak public sector action to contain risks

11. Vulnerability and the health professional
Health professionals often in the middle  Dual Loyalty conflicts:
Asbestos: “…because company doctors owed their livelihood to mine owners, there was little incentive to diagnose diseases with a longer latency than the worker’s tenure in the mine …” (Braun and Kisting, 2006)

12. Vulnerability and the health professional: Dual Loyalty
Chromium: The “WHO standard was “perhaps overly punitive … “exaggerated reports in the press” failed to appreciate that “one can be exposed to mercury and can tolerate it well…” ?? “…dancing to the piper’s tune...” (van der Linde, 1995)

13. Dual Loyalty guidelines
Individual practice: emphasise independence
Institutional mechanisms targeting structural factors
But little institutional capacity in Africa
Professional organisations weak
Little capacity to assert independence
Little ethical training
Health workers as targets of violence

14. Autonomy and Consent
Workplace power imbalance impacts autonomy to make decisions
HC provider to proactively protect worker’s autonomy?
Most OHS interventions are employer-initiated
Individual autonomy vs. ubuntu: “I am because we are”  require time to consult family members for consent
Patriarchy and women workers’ autonomy
Distinction mandatory and voluntary programs?
Meaningful comprehension for informed consent
Workers as ends in themselves, not mere means to an end

15. Stigma Epitomised by HIV at workplace
“… a good name is better than riches …”
Contradicts binary constructs of identity & solidarity
“… elements of labelling, stereotyping, separation, status loss, and discrimination co-occur in a power situation that allows the components of stigma to unfold…” (Link and Phelan, 2001)
Stigma is contingent on power – to stigmatise is to express power

16. Stigma disrupts solidarity and harmony of the group
HIV “as a ‘polluted disease”, result of immorality, sinful and evil deeds: Destabilizes the tranquillity of a traditional African society
Workplace examples: Hoffman vs SAA Constitutional court reversed decision
AIDS-related stigma  ostracism, violence
Confidentiality of information

17. Who is the workforce?
“… the aim of occupational health practice is to protect and promote workers’ health and wellbeing at work throughout their working lives...’’ ? Suited if high levels formal employment
In Africa, intimate relationship between the work and the home

18. Bernardino Ramazzini …
“ … it appeared that many more persons died in that quarter and in the immediate neighbourhood of the laboratory than in other localities …” [Franco, 1999].
Pollution from work environment affects people living in the vicinity of the workplace

19. Work-to-home pathways…
… living near asbestos mines; on farms using pesticides, etc
Toxins brought home on clothing…

20. Mining Single-sex hostels = incubator for HIV Burden of silicosis, TB
Circulation of TB urban to rural has driven TB epidemic in Southern African region
Extended concept of what is ‘occupational’

21. Conclusion Recognise need for empirical evidence
Dominant bioethics paradigms focus on clinical care, neglect prevention, population-based approaches, advocacy and health promotion to address the social determinants of health (Azetsop, 2009)
Ethical Guidelines should address power and vulnerability – from workplace to global

22. “The unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is a result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics.” [WHO, 2008]
Our experience in Africa points to the need for Ethical Codes to challenge inequalities in power at the workplace, rather than assuming them as given.

23. Ubuntu and Occupational Health
Rethink bioethical approaches to consent, stigma and the scope of OH practice
Operationalising the idea that ‘a person is a person through other persons’ in our Ethical Codes
Will strengthen moral authority of ethical codes, and …
… more likely to “protect and promote workers’ health and wellbeing throughout their working lives” in an African context

24. Ethics, human rights and OH in Africa
Citizens claim rights from states
Made real when states meet obligations; Civil Society act as agents for rights
Responsibility of governments in Africa to adapt + supplement international norms
African Charter on Human and Peoples Rights as response to UDHR
An Afro-centric African Charter on Bioethics to draw on both ‘Western’ and traditional African philosophy